Provider Demographics
NPI:1740993856
Name:DUFERA, GIRMA
Entity type:Individual
Prefix:
First Name:GIRMA
Middle Name:
Last Name:DUFERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14511 LOCKSLIE TRL
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-2257
Mailing Address - Country:US
Mailing Address - Phone:612-517-8429
Mailing Address - Fax:
Practice Address - Street 1:14511 LOCKSLIE TRL
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-2257
Practice Address - Country:US
Practice Address - Phone:612-517-8429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1110719320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities